Ulcers

An ulcer occurs when part of the lining of the stomach or intestines becomes deeply eroded. This typically happens in the stomach (gastric ulcer) or the in the duodenum (duodenal ulcer), which is located at the lower end of the stomach and the beginning of the small intestine. Ulcers range from quite small to an inch or more in size.

Symptoms

Symptoms vary depending on where the ulcer is and how old the patient is. Many patients, especially older ones, may have no symptoms. When symptoms do occur, they tend to come back again and again.

Stomach (or peptic) ulcers may produce few or no symptoms, or they may cause burning, gnawing pain in the upper middle part of the abdomen that is relieved by eating or taking an antacid. Stomach ulcers often are not consistent. For example, eating sometimes will make the pain worse rather than better with certain types of ulcers, such as pyloric channel ulcers, which are often associated with bloating, nausea and vomiting, symptoms of a blockage caused by swelling (edema) and scarring.

Duodenal ulcers tend to cause consistent pain. A patient may feel no pain when he or she awakens, but by midmorning it is present. The pain can be relieved by eating, but it usually returns two to three hours later. Pain that wakes a patient at night is common for duodenal ulcers.

Causes and Risk Factors

At one time ulcers were believed to be the result of too much stomach acid. It is now known that the main factors that lead to ulcers are the bacteria H. pylori and non-steroidal anti-inflammatory drugs (NSAIDS). These disturb the normal defense and repair processes of the mucosal linings, making them more vulnerable to attack from stomach acid.

How H. pylori causes ulcers is not entirely clear. One theory is that the organism causes ammonia to be created so that it can survive in the stomach's acid. The ammonia may then erode the mucous barrier that protects the cells of the digestive tract. Other poisons and enzymes from the bacteria may also be a cause, and proteins produced by the body in response to inflammation may play a role.

NSAIDs tend to cause inflammation of the GI tract lining. Weak acids themselves, NSAIDS cause a number of changes within the stomach, including reduced flow of blood to the stomach, less mucus production, and less cell repair and reproduction. All of these tend to break down the process of defense and repair that keeps the mucosa healthy.

Diagnosis

A doctor usually bases a diagnosis of peptic ulcer on the patient's history. A physician will want to rule out the presence of stomach cancer, which can have similar symptoms. This is especially true in patients who are older, have lost weight, have severe symptoms or do not respond to treatment.

The diagnosis can be confirmed through a variety of studies, such as:

Endoscopy, which uses a camera attached to the end of a flexible tube to allow the doctor to see inside the body. This can reliably detect swelling and irritation (inflammation) of the esophagus and esophageal ulcers as well as H. pylori infection.

Cytology (examination under a microscope of cells from the affected area)

Multiple biopsies

X-rays or CT scans to identify ulcers that have caused holes in the stomach or intestines

Treatments

In the past, ulcers were treated by trying to neutralize or decrease the amount of acid in the stomach. Current treatment focuses on eliminating H. pylori through antibiotics. Antibiotic treatment should be given to all ulcer patients who have been diagnosed with H. pylori, even if they have no symptoms or are being treated to reduce stomach acid. Antibiotic treatment is especially important for patients who have had complications in the past. Antibiotics to treat H. pylori are evolving, and a combination of antibiotics is usually prescribed.

The symptoms of an ulcer can be relieved by taking antacids, which can also help prevent the symptoms from coming back and help promote healing of the ulcer. Antacids must be taken five to seven times a day and can interfere with the body's ability to absorb other drugs. The two general types of antacids are:

Ones that the body can absorb, such as baking soda. These are quick and effective but may have side effects when taken on a regular basis

Ones that interact with stomach acid to create salts that are not absorbed by the body and are excreted

While there is currently no evidence that changing the diet helps an ulcer heal faster or prevents its return, a doctor may suggest that any food that causes distress be eliminated. These may include fruit juices, spicy foods and fatty foods.

Alcohol tends to increase the acid in the stomach, and ulcer patients are usually advised to restrict their drinking of alcohol. Persons who smoke are at a higher risk of developing ulcers and complications. Smoking also slows the healing process and makes the return of ulcers more likely.

Although surgical treatment is being prescribed less often, surgery may be necessary if complications do not respond to medical therapy, symptoms are severe or there is a suspicion that the ulcer may be cancerous.

More than 60% of people have a return of their ulcers a year after traditional treatment has ended. Fewer than 10% of people have a recurrence of ulcers after anti-H. pylori therapy. The use of non-steroidal anti-inflammatory drugs might also affect recurrence of ulcers.

Complications

Certain complications can also result from peptic ulcers, including:

Bleeding

A hole in the wall of the stomach or duodenum. This causes intense, ongoing pain that may be felt in locations other than the abdomen. The pain may change with shifts in body position.

A hole into the peritoneal cavity, which surrounds the organs of the abdomen. This causes sudden, intense pain that spreads quickly throughout the abdomen and is worse with movement.

A blockage. The outlet of the stomach may become blocked as a result of scarring, muscle spasms or inflammation related to an ulcer. This causes repeated, high volume vomiting, usually at the end of the day. There may also be a feeling of bloating after eating and a loss of appetite. Dehydration and weight loss are risks if vomiting continues.

Treatment of complications varies. For example:

Bleeding may be stopped using a variety of minimally invasive techniques.

Acid-suppressing drugs may be given intravenously and continued until the condition stabilizes.

Emergency surgery may be necessary if the patient gets worse even with treatment and blood transfusions and if their pulse rate and blood pressure are not stable.

Persons who have H. pylori-related ulcers may be at higher risk for certain forms of cancer and lymphoma.